Exocrine Pancreatic Insufficiency


Step 1: View clinicals

A 55-year-old man complains of passing pale stools for around one month. The stools are malodorous and difficult to flush away. He has also lost around four kilograms of weight during this time. He was diagnosed with pancreatic cancer three months ago, after being investigated for jaundice. He refused surgery and was treated palliatively with biliary stenting. He has been drinking around 10 to 15 units of alcohol per week for almost three decades now and has a smoking history of 30 pack-years. He continues to drink and smoke at the same levels even after his diagnosis. A complete blood count is significant for a Hb of 10.9 mg/dL, with a blood film showing normochromic normocytic anemia. A liver profile is significant for an ALT of 78 U/L (normal: 7-56), AST of 62 U/L (normal: 10-40), GGT of 55 U/L (0-45), total bilirubin of 1.9 mg/dL (normal: 0.3-1.9), direct bilirubin of 0.2 mg /dL (normal: <0.3), and INR of 1.6 (normal: 0.9-1.1). ALP and serum albumin are within normal parameters.

Step 2: Order all relevant investigations

Fecal elastase-1 levels

Fecal elastase-1 levels: 80 μg/g (normal: >200)

Anti-TTG IgA levels

Anti-TTG-IgA: 20 U/mL (normal: <50)

Helical CT Abdomen

You realize that helical computed tomography (CT) of the abdomen is of little value here.

Whole body 18F-FDG PET

You realize that whole-body 18F-FDG PET imaging is of little value here.

Step 3: Select appropriate management

Pancreatic enzyme replacement therapy
Vitamin K supplementation
Restrict fat intake
Proton pump inhibitors

Score: ★★☆